Plastic & Reconstructive Surgery:
Wilhelm, Albrecht M.D.
Schongauerstraße; D-63739 Aschaffenburg, Germany; firstname.lastname@example.org
I read with great interest the article entitled “Partial Joint Denervation I: Wrist, Shoulder, and Elbow,” published by A. Lee Dellon in the January 2009 issue of the Journal (Plast Reconstr Surg. 2009;123:197–207). Initially Dellon holds the opinion that a neurogenic origin of pain has not yet been mentioned in differential diagnosis, and he makes the absence of illustrations of joint innervation in anatomic texts responsible. This opinion, however, does not consider the publications of Rüdinger (1859) and Gardner (1948),1) or those of Wilhelm (1958)1,2 and von Lanz and Wachsmuth (1959).3 Thus, joint innervation has been well known for a long time!
Wrist Joint. In 1966, I described the denervation of the wrist.2,4 Since that time, 95 of 139 cases have been partially denervated and 44 patients have been completely denervated. This is a ratio of about 2:1 in favor of partial denervation.4 Total denervation, which would also include the palmar articular fibers of the ulnar nerve, has never been necessary.
In the indication for pain elimination, one should always consider the results of each test blocking! The proposition to only eliminate the “critical nerve branches” should only be discussed for the time being, as there are no final results.
Shoulder Joint. The most severe pains are found in the anterior upper quadrant of the shoulder joint and over the coracoid. Mainly a direct connection of the inferior cervical ganglion by an articular branch entering between coracoid and subscapular muscle into the joint capsule is responsible. This articular branch was confirmed histologically by Gardner (1948)1 and macroscopically by me.1
Based on my own findings in 1960, a simple injection procedure was developed.1 First, the already known blocking of the suprascapular nerve is performed to eliminate the posterior articular nerves. Afterward, the articular branch of the anterior cranial thoracic nerve innervating the coracoid and finally the acromioclavicular joint is eliminated (Fig. 1). The needle is inserted over the tip of the coracoid and then infiltrates the fan-shaped soft tissue over the clavicle (Fig. 2). Then the remaining anterior articular branches are eliminated (Fig. 1). The needle is drawn back and turned over by 90 degrees and then moved to the humeroscapular joint cavity. Below the coracoid a larger depot is administered between the subscapular and coracobrachial muscles. Most articular nerves, as well as the sympathetic articular branch, run in this gliding layer. Finally, by subsequent diffusion of the anesthetic, the articular nerve endings of the deep layer, originating from the four subscapular nerves, can be blocked. An injury of the vascular nerve bundle is impossible!
Denervation of the articular branch of the acromioclavicular joint and of the sympathetic articular branch was discussed earlier in 1963.1
Tennis Elbow. I held the opinion that the success of surgery at the extensor tendons is based on an unconscious denervation as early as 1962.2 An anterior radial branch running through the brachioradial muscle has never been cut by me.
Golfer's Elbow. In addition to this communication, see my letter to the editor published in the Journal of Hand Surgery (Edinburgh, Scotland).5
The author has no financial interest to declare in relation to the content of this communication.
Albrecht Wilhelm, M.D.
D-63739 Aschaffenburg, Germany
1. Wilhelm A. Die gezielte Schmerzausschaltung am Schultergelenk und ihre anatomischen Grundlagen [The elimination of pain at the shoulder joint and its anatomical basis]. Langenbecks Arch Klin Chir. 1963;302:799–809.
2. Wilhelm A. Die Eingriffe zur Schmerzausschaltung durch Denervierung [The operations for pain elimination by denervation]. In: Wachsmuth W, Wilhelm A, eds. Die Operationen an der Hand [The operations on the Hand]. Allgemeine und Spezielle Chirurgische Operationslehre [General and Special Operative Surgery]). Vol. X, Part 3, 1st ed. Berlin: Springer-Verlag, 1972;50–54;264–285.
3. von Lanz T, Wachsmuth W. Praktische Anatomie [Practical anatomy]. 2nd ed, Vol 1, Part 3. Berlin: Springer-Verlag, 1959;106–107;162–163;232–233;256.
4. Wilhelm A. Denervation of the wrist. Tech Hand Upper Extrem Surg. 2001;5:14–30.
5. Wilhelm A. Re: the innervation of the medial humeral epicondyle: Implications for medial epicondylar pain, Dellon et al., Journal of Hand Surgery, 31B: 331-333. J Hand Surg (Br.) 2008;33:542.
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article's publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.
Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS' enkwell, at www.editorialmanager.com/prs/.
We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.